Download Circulation - Southwest General Health Center

EMS Services
Section 4
PRE-HOSPITAL CARE
MEDICAL CONTROL
PROTOCOLS AND PROCEDURES
TABLE OF CONTENTS
4. CIRCULATION / SHOCK PROTOCOLS
Shock Guidelines
Anaphylactic Shock
Hypovolemic / Neurogenic / Cardiogenic / Septic Shock
Southwest General Health Center / EMS Services
Revised 03 2007, 06/2007, 08/2008, 01/2012, 05/2015, 6/2016
pages
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CIRCULATION / SHOCK
SHOCK GUIDELINES
TYPES OF SHOCK
ANAPHYLACTIC
SHOCK
(DISTRIBUTIVE
SHOCK)
CARDIOGENIC
SHOCK
HYPOVOLEMIC
SHOCK
MECHANICAL
SHOCK
(OBSTRUCTIVE)
NEUROGENIC
SHOCK
(DISTRIBUTIVE
SHOCK)
SIGNS AND SYMPTOMS
• Warm, burning feeling
• Itching
• Rhinorrhea
• Hoarseness / Stridor
• Wheezing
• Shock
• Severe Respiratory Distress
• Altered LOC / Coma
• Cyanosis
• Pulmonary Edema
• Facial / Airway Edema
• Urticaria / Hives
• Dyspnea
• Cool, clammy skin
• Weakness
• Difficulty breathing
• Hypotension
• Tachycardia
• Weak, thready pulse
• Hypotension with narrow pulse pressure
• Hypotension or falling systolic BP
• Pale skin
• Clammy or dry skin
• Dyspnea
• Altered LOC/ Coma
• Decreased urine output
• Restlessness
• Irritability
• PE (pulmonary embolism), Tension Pneumothorax, Cardiac
Tamponade
• Altered LOC
• Difficulty breathing
• Weak, thready, rapid pulses
• Pale/cool/diaphoretic skin
• Cyanosis
• JVD
• Muffled heart tones
• Tracheal deviation
• Absent/diminished breath sounds
• Evidence of trauma (lacerations, bruising, swelling, deformity)
• Normal or Bradycardiac HR
• Hypotension with narrow pulse pressure
• Compromise in neurological function
• Normal or flush skin color
Southwest General Health Center / EMS Services
Revised 03 2007, 06/2007, 08/2008, 01/2012, 05/2015,06/2016
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CIRCULATION / SHOCK
SHOCK GUIDELINES
SEPTIC SHOCK
(DISTRIBUTIVE
SHOCK)
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Tachycardia
Hypovolemia
Hypotension with narrow pulse pressure
Dehydration
Altered LOC /Coma
Dyspnea
Febrile / Hx of UTI
Signs of Infection
Southwest General Health Center / EMS Services
Revised 03 2007, 06/2007, 08/2008, 01/2012, 05/2015,06/2016
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CIRCULATION / SHOCK
SHOCK GUIDELINES
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History
Blood loss - vaginal or
gastrointestinal bleeding,
AAA, ectopic
Fluid loss - vomiting,
diarrhea, fever
Infection
Cardiac ischemia (MI, CHF)
Medications
Allergic reaction
Pregnancy
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Signs and Symptoms
Restlessness, confusion
Weakness, dizziness
Weak, rapid pulse
Pale, cool, clammy skin
Delayed capillary refill
Hypotension
Coffee-ground emesis
Tarry stools
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Differential Diagnosis
Shock / Vasovagal Syncope
Hypovolemic
Cardiogenic
Septic
Neurogenic
Anaphylactic
Ectopic pregnancy
Dysrhythmias
Pulmonary embolus
Tension pneumothorax
Medication effect / overdose
Physiologic (pregnancy)
GENERAL CONSIDERATIONS:
• Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro
• Hypotension can be defined as a systolic blood pressure of less than 100.
• Consider all possible causes of shock and treat per appropriate protocol.
Anaphylactic Shock (Distributive)
• Do not confuse epinephrine 1:1000 and 1:10,000.
• Routine assessment and supportive care of the patient’s respiratory and cardiovascular systems is required.
• Treat patients with a history of anaphylaxis aggressively.
• Call Med. Control and use caution when using epinephrine for patients over sixty-five years of age.
• Call Med. Control and use caution when using epinephrine for patients with a heart rate greater than 150 bpm
or a history of ASHD.
• When possible, remove any stingers.
• Consider glucagon for elderly, pregnant and ASHD.
Cardiogenic Shock
• Circulatory failure is due to inadequate cardiac function.
• Be aware of patients with congenital defects.
• Cardiogenic shock exists in the pre-hospital setting when an MI is suspected and there is no specific indication
of volume related shock.
• Pulmonary Edema or CHF may cause cardiogenic shock (pediatrics with congenital heart defects may rarely
have pulmonary edema).
• Marked, symptomatic tachycardia and bradycardia will also cause cardiogenic shock.
Hypovolemic Shock
• Patients suffering from hemorrhagic shock secondary to trauma, should be treated under the Trauma Criteria,
• and should be rapidly transported to the nearest appropriate facility.
• Initiate a second large bore IV for all patients in hypovolemic shock.
Mechanical Shock (Obstructive)
• Caused by diminished cardiac output.
• Blood backs up into the venous system causing distended neck veins.
• Lungs are not perfused well causing cyanosis.
• Catecholamine release causes tachycardia.
• A post-trauma patient with signs of mechanical shock is near death.
• Tension pneumothorax requires immediate needle decompression.
Southwest General Health Center / EMS Services
Revised 03 2007, 06/2007, 08/2008, 01/2012, 05/2015,06/2016
4
CIRCULATION / SHOCK
SHOCK GUIDELINES
Neurogenic Shock (Distributive)
• Cushings Reflex is a sign of increased ICP. Cushings Reflex is a high blood pressure, low pulse rate, and
irregular respirations.
Septic Shock (Distributive)
• Hypotensive patients are a priority and require aggressive intervention.
• If B/P less than 90mmHg systolic-administer 500cc IV fluid bolus.
• Repeat to maintain BP greater than 90mmHg systolic.
• Be alert for septic shock in the elderly.
• Start an IV and maintain systolic blood pressure greater than 90 for end organ perfusion.
Southwest General Health Center / EMS Services
Revised 03 2007, 06/2007, 08/2008, 01/2012, 05/2015,06/2016
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CIRCULATION / SHOCK / MEDICAL EMERGENCY
ANAPHYLACTIC SHOCK
UNIVERSAL PATIENT CARE PROTOCOL
B
A
P
M
EMT-B
EMT-A
EMT-P
MED CONTROL
B
A
P
M
IV Protocol
Apply Cardiac Monitor and Assess Vitals
Mild
Moderate
Hives, Rash, itching,
NO difficulty
breathing or throat
tightening,
BP – normal limits
Rash, itching,
Wheezing,
Throat tightening,
Swelling, face lips,
BP – normal limits
Treatment
Treatment
Treatment
Oxygen per
cannula
Oxygen per NRB
Oxygen per NRB
Benadryl 25-50
mg IV or IM
Assist with
Epi-pen
Assist with
Epi-pen
*For patients over
65 yrs. in category
mild, moderate or
severe, may give
Glucagon 1 mg
IV/IM before EPI
Epinephrine 1:1000
0.3-0.5 mL IM/SQ
Consider Epi if
history of severe
reaction
Consider assisting
with Epi pen if
history of severe
reaction
200-400 mL
Epinephrine 1:1000
0.3-0.5 mL IM/SQ
Benadryl 25-50
mg IV or IM
IV with NS-Bolus
Consider
Albuterol
aerosol tx.
Severe
Rash, itching,
Airway compromise
Wheezing,
Swelling,
Hypotension
Benadryl 25-50
mg IV or IM
Treatment
Epinephrine 1:10,000
0.3-0.5mg IVP
*For patients over 65
yrs. in category mild,
moderate or severe,
may give Glucagon 1
mg IV/IM before EPI
IV NS wide open
airway via BVM
Control airway via
BVM
Albuterol Aerosol
watch airway &
breathing
Follow ACLS
Consider repeat
Epi after
5 min. if no
improvement
Consider Dopamine
if no improvement
Southwest General Health Center / EMS Services
Revised 03 2007, 06/2007, 08/2008, 01/2012, 05/2015, 06/2016
Severe Hypotension
No response to Epi
Decreased level of
consciousness
Airway compromise
IV with NS-Bolus
200-400 mL
CONTACT MEDICAL CONTROL
TRANSPORT
(Adult Any Age)
Impending Arrest
Contr
ol
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AIRWAY / BREATHING / CIRCULATION / SHOCK ACLS MEDICAL TRAUMA
HYPOVOLEMIC, NEUROGENIC CARDIOGENIC AND SEPTIC SHOCK
UNIVERSAL PATIENT CARE PROTOCOL
B
A
P
M
EMT-B
EMT-I
EMT-P
MED CONTROL
B
A
P
M
Airway Protocol
Monitor Lung Sounds for Fluid Overload
Consider Spinal Immobilization
IV / IO PROCEDURE
Apply Cardiac Monitor and Assess Vitals
Hypovolemic Shock
IV NS/LS BOLUS
500 mL
(If BP less than 90
Systolic)
Check Blood
Glucose Level
IV NS/LR BOLUS
500 mL
(If BP less than 90
Systolic)
Treatment per
Appropriate Trauma
Protocol
Cardiogenic Shock
Neurogenic Shock
Septic Shock
IV NS BOLUS 500 mL
(If BP less than 90
Systolic)
IV NS TKO
12 Lead Procedure
Check Blood
Glucose Level
Dopamine
(Intropin)
2 - 20 mcg/kg/min
IV drip
Titrate to effect (if
B/P < 90 systolic)
IV NS BOLUS
500 mL
(If BP less than
90 Systolic)
12 Lead Procedure
Check Blood
Glucose Level
Check Blood Glucose
Level
IV NS
BOLUS 500
mL
(If BP less
than 90
Systolic)
Dopamine (Intropin)
2 - 20 mcg/kg/min IV
drip
Titrate to effect (if B/P <
90 systolic)
Monitor and Reassess BP
CONTACT MEDICAL CONTROL
IV NS BOLUS 500 mL
(If BP less than 90
Systolic)
Repeat as needed
CALL a “SEPSIS ALERT” for TWO (2) of
the following and with S/S and/or
history of recent infection:
*Body temp:
101* (38.3) or
*Heart Rate
90
*Resp. Rate
20
*Blood Glucose
*Systolic B/P
140 -esp. non-diabetic pt
90
TRANSPORT
Southwest General Health Center /EMS Services
Revised 03/2007, 01/2012, 05/2015, 06/2016
96.8* (36)
Circulation/Shock